Medicare vs. Medicare Advantage: What’s the Difference?

 Medicare vs. Medicare Advantage: What’s the Difference?

Understanding your options can save you time, money, and frustration. Here’s how the two systems compare — and where people often get confused.

🏛️ 1. Who Runs the Program


Original Medicare

Medicare Advantage (Part C)

Administered by

The federal government (Centers for Medicare & Medicaid Services – CMS)

Private insurance companies approved by Medicare

Regulation

Directly follows Medicare laws and coverage rules

Must follow Medicare rules but can set additional policies and restrictions

💰 2. Cost Structure


Original Medicare

Medicare Advantage

Premiums

You pay Part B premium (and sometimes Part A)

You still pay the Part B premium, plus possibly an extra plan premium

Out-of-Pocket Costs

20% coinsurance for most services after deductible

Copays or coinsurance vary by plan; annual out-of-pocket maximum protects you once you hit the limit

Supplemental Options

You can buy a Medigap plan to cover what Medicare doesn’t

Medigap not allowed; you rely on the plan’s cost structure and rules

🩺 3. Provider Access


Original Medicare

Medicare Advantage

Choice of Doctors

See any provider nationwide who accepts Medicare

Must use the plan’s network (HMO, PPO, etc.) except emergencies

Referrals

Usually not required

Often required for specialists (especially HMOs)

💊 4. Prescription Drug Coverage


Original Medicare

Medicare Advantage

Drug Coverage

Separate Part D plan needed

Most include Part D drug coverage automatically

Formularies & Restrictions

Set by the Part D plan you choose

Each plan’s PBM sets its own formulary and rules (prior auth, step therapy, etc.)

🧾 5. Additional Benefits


Original Medicare

Medicare Advantage

Extras

Limited to what’s medically necessary under Medicare rules

May include extras like dental, vision, hearing, fitness, or OTC allowances

Home & Community-Based Benefits

Rare

Some plans include transportation, meals, or in-home support

⚖️ 6. Flexibility vs. Convenience

  • Original Medicare: More freedom in choosing providers and fewer administrative hurdles, but less protection from out-of-pocket costs unless you buy Medigap.

  • Medicare Advantage: More convenient (bundled coverage, single card), but more restrictions on doctors, referrals, and prior authorizations.

💬 AKG Advocacy Tip

“Medicare Advantage plans can sound attractive with added benefits, but they operate more like managed care plans. Always compare the provider network, drug formulary, and annual maximums before enrolling — and remember, you can appeal denials under both systems.”

Comments

Post a Comment

Popular posts from this blog

Top 10 Resources Every Patient Advocate Should Know

  Empowering yourself with the right tools can make all the difference when advocating for care, coverage, and fairness. 1. Medicare Coverage Database (MCD) Website: https://www.cms.gov/medicare-coverage-database This database provides official Medicare coverage determinations (both National and Local). Advocates can check whether a service or treatment is “reasonable and necessary” and see how different regions interpret coverage rules. 2. FDA Drug Databases Website: https://www.fda.gov/drugs Includes the Orange Book (approved drugs), Purple Book (biologics), and NDC Directory . These are essential for verifying FDA approval status and identifying whether compounded medications or ingredients are covered. 3. State Department of Insurance Each state’s Department of Insurance has a consumer assistance division that helps with appeals, external reviews, and complaints against insurance companies. Tip: Look for “Consumer Complaints,” “External Review,” or “Appeals” sect...
Read more

How to Prepare for a Doctor Appointment When You Have a Complex Condition

  Because managing your health shouldn’t feel like managing a full-time job. When you live with multiple diagnoses, rare diseases, or chronic conditions, a doctor’s appointment can feel overwhelming. Between remembering your medication list, explaining symptoms, and staying calm while trying to be heard, it’s easy to walk out realizing you forgot half of what you wanted to say. This guide helps you take back control — so you can make every appointment efficient, productive, and empowering. 1. The Truth About Complex Care If you have a complex or chronic condition, you’re not “just another patient.” You’re often managing: Multiple specialists and conflicting instructions A long medication list Frequent labs and tests Insurance authorizations and denials Emotional exhaustion from advocating for yourself 💡 AKG Insight: Complex care requires preparation, not perfection. When you plan ahead, you shift the power dynamic — and doctors listen differently. 2. Be...
Read more